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Launch of Safe Childbirth Checklist Offers New Approach to Improving Care for Mothers and Infants in Childbirth

By: Katherine Semrau, Director of the BetterBirth Program at Ariadne Labs, Assistant Professor at Harvard Medical School and Associate Epidemiologist at Brigham and Women's Hospital Division of Global Health Equity

 Katherine Semrau

Safe Childbirth Checklist India BetterBirth maternal newborn neonatal mortalityAlthough great strides have been made, women and their newborns are still dying in childbirth at unacceptably high rates all over the world. I have seen firsthand the immense suffering within families and communities when these needless deaths occur. These deaths happen to otherwise healthy women, a tragedy impacting women, families and their communities. When mothers die in childbirth, the infants too have a greater likelihood of dying. At times, their babies are delivered stillborn, causing immense family grief.

To help solve this problem, the World Health Organization has just launched the revised Safe Childbirth Checklist and an accompanying Implementation Guide for public download and dissemination. Until now, there was limited access to this tool as it was being piloted and adapted by 34 groups in 29 countries. The idea for the Safe Childbirth Checklist emerged from the success of the WHO’s Safe Surgery Checklist, which is now the WHO global standard of care and has been shown to reduce surgical complications and death by 18 to 47 percent.

In coordination with the World Health Organization, Ariadne Labs is championing this new approach. Checklists have proven an invaluable tool in numerous high-risk industries such as airlines and construction. Every time you fly on an airplane, checklists are used to ensure that the basic, standard and essential practices are completed. The high-rises that fill our cities are built using checklists that ensure essential standards and steps are followed, in the right sequence.

Over the years, many strategies have been deployed to prevent the death of laboring women and their newborns – and many have worked. Most interventions have focused on enhancing women’s access to health care facilities that can provide a skilled birth attendant. This approach has improved access to care, but that alone has not solved the problem. While maternal and neonatal death rates have dropped, we still have work to do. We now understand that the quality of care provided during childbirth is not meeting basic standard practices.

Safe Childbirth Checklist India BetterBirth maternal newborn neonatal mortality

BetterBirth coaches introduce WHO Safe Childbirth Checklist to their peers in Uttar Pradesh, India

The WHO Safe Childbirth Checklist (SCC) includes basic standard practices and reflects the same principles as the Safe Surgery Checklist. It ensures clinicians do what we already know works best. The SCC includes 28 essential childbirth practices such as assessing maternal temperature and blood pressure, providing oxytocin within one minute of delivery and putting the mother and infant skin-to-skin (chest-to-chest) after delivery. The practices are grouped into four pause points during the birthing process—admission, just before pushing (or c-section), within one hour of delivery and discharge—and can make a significant impact on quality of care.

I believe the strength of a checklist lies in its simplicity. The Safe Childbirth Checklist does not require expensive technology or much additional time to implement. It does, however, require commitment from birth attendants and facility leadership to use the checklist with each and every laboring woman.

Our testing of the Safe Childbirth Checklist has shown us that it makes a difference. Specifically the checklist helps clinicans

  • focus on the basic care that every woman and newborn should receive,
  • organize the labor and delivery room with appropriate supplies,
  • streamline basic practices, and
  • highlight critical life-saving basic practices.

Like any public health intervention, a checklist cannot be airlifted in to a childbirth facility and dropped off. “Culture eats strategy for breakfast,” said Peter Drucker, and I agree. In essence, a checklist has to make sense and be achievable in the facility where it is introduced. Adaptation of the Safe Childbirth Checklist is essential to ensure that it can be used easily and effectively.

As part of the accompanying Safe Childbirth Checklist Implementation Guide, we, along with our partners at Population Services International, identified a strategy that has been effective in introducing and adapting the checklist. Engaging facility staff and leadership, launching the checklist and supporting its use over time are critical steps to ensuring successful and sustainable use of the checklist.

The process starts with a commitment. Then, through consistent use, the checklist can create profound, lasting and systemic behavior change and a cultural shift in a health facility. It is hard work: Implementing simple tools is not easy. Creating this kind of change requires buy-in and acceptance and a willingness to listen, test, adapt and follow the checklist consistently.

We have the continued opportunity and moral obligation to reduce and even stop maternal and neonatal deaths, especially since most deaths that occur within the first 24 hours of childbirth are preventable. From country to country, the reasons why 300,000 women and 2.7 million babies die every year—often hemorrhage, obstructed labor, infections and neonatal asphyxia— are consistent and well-documented. These are problems that we can solve, whether they occur in India, the United States, or Namibia.

I am hopeful that we can save the lives of more and more women and their newborns through a focus on improving the quality of care. The Safe Childbirth Checklist makes clear the essential practices for every woman and newborn. The systemic change we seek starts with one health facility, one birth attendant and one laboring mother and her infant at a time.

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